Contact Us (P) 888-467-3330 ext. 102
(F) 888-453-5755

Quick Quote

General Information

 

Complete Legal Name

 
Street Address
City
State
Zip
Phone (required)
Email (required)
Fax
Website
Contact
Years in business

Package Insurance

Name of current insurance company
Expiration date
Building Coverage
$
Contents Coverage
$
Square footage of space you occupy
Square footage of your building
Year built  
If built before 1990 last updated
# of stories
Sprinkler system in building YesNo Central station alarm YesNo
Refrigeration maintenance agreement YesNo Value of unattached sign
Does your store do any cooking? YesNo If yes, is there an ansul system YesNo
Total estimated annual sales
$
Total sales of privately labeled/relabeled sales
Total value of point of sale system $ Total value of product stored in refrigeration $
Liquor Sales $ Is alcohol served on premises? YesNo
Is there a restaurant located in the entire building you occupy? YesNo
Are there residential apartments located in your building? YesNo
Are you involved in any other type of business? YesNo

Building Construction

Umbrella

Umbrella YesNo Limit$

Workers Comp

 
Name of current insurance company Expiration date
Cannot Quote WC Without the FEIN
FEIN -
Experince Mod Exec. officers included YesNo
Class / Code
Payroll
Store / 8017 $
Store / 8006 $
Clerical / 8810 $
Other $

Claims

 
Number of property and liability claims
in last 5 years
Amount $
Number of workers comp claims
in last 5 years
Amount $
Comments
Completed by: Date
If you have any questions please contact Mark Kapatoes
Phone - 203-507-6068
Email - Mark@kisllc.com